Texas 2025 - 89th Regular

Texas Senate Bill SB1156 Compare Versions

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

Old	New	Differences
1	1	89R13255 SCF-F
2	2	By: Hughes S.B. No. 1156
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7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to prohibited conduct of a health benefit plan issuer in
10	10	relation to affiliated and nonaffiliated providers.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Subtitle F, Title 8, Insurance Code, is amended
13	13	by adding Chapter 1462 to read as follows:
14	14	CHAPTER 1462. AFFILIATED PROVIDERS
15	15	Sec. 1462.001. DEFINITIONS. In this chapter:
16	16	(1) "Affiliated provider" means a health care provider
17	17	that directly, or indirectly through one or more intermediaries,
18	18	controls, is controlled by, or is under common control with a health
19	19	benefit plan issuer.
20	20	(2) "Nonaffiliated provider" means a health care
21	21	provider that does not directly, or indirectly through one or more
22	22	intermediaries, control and is not controlled by or under common
23	23	control with a health benefit plan issuer.
24	24	Sec. 1462.002. APPLICABILITY OF CHAPTER. This chapter
25	25	applies only to a health benefit plan that provides benefits for
26	26	medical or surgical expenses incurred as a result of a health
27	27	condition, accident, or sickness, including an individual, group,
28	28	blanket, or franchise insurance policy or insurance agreement, a
29	29	group hospital service contract, or an individual or group evidence
30	30	of coverage or similar coverage document that is offered by:
31	31	(1) an insurance company;
32	32	(2) a group hospital service corporation operating
33	33	under Chapter 842;
34	34	(3) a health maintenance organization operating under
35	35	Chapter 843;
36	36	(4) an approved nonprofit health corporation that
37	37	holds a certificate of authority under Chapter 844;
38	38	(5) a multiple employer welfare arrangement that holds
39	39	a certificate of authority under Chapter 846;
40	40	(6) a stipulated premium company operating under
41	41	Chapter 884;
42	42	(7) a fraternal benefit society operating under
43	43	Chapter 885;
44	44	(8) a Lloyd's plan operating under Chapter 941; or
45	45	(9) an exchange operating under Chapter 942.
46	46	Sec. 1462.003. EXCEPTION TO APPLICABILITY OF CHAPTER. This
47	47	chapter does not apply to an issuer, provider, or administrator of
48	48	health benefits under:
49	49	(1) the state Medicaid program, including the Medicaid
50	50	managed care program operated under Chapter 540, Government Code;
51	51	(2) the child health plan program under Chapter 62,
52	52	Health and Safety Code;
53	53	(3) a basic coverage plan under Chapter 1551;
54	54	(4) a basic plan under Chapter 1575;
55	55	(5) a coverage plan under Chapter 1579;
56	56	(6) a plan providing basic coverage under Chapter
57	57	1601; or
58	58	(7) a workers' compensation insurance policy or other
59	59	form of providing medical benefits under Title 5, Labor Code.
60	60	Sec. 1462.004. REIMBURSEMENT OF AFFILIATED AND
61	61	NONAFFILIATED PROVIDERS. (a) A health benefit plan issuer may not
62	62	offer a higher reimbursement rate to a health care practitioner who
63	63	is a member of a nonaffiliated provider based on a condition that
64	64	the practitioner agrees to join an affiliated provider.
65	65	(b) A health benefit plan issuer may not pay an affiliated
66	66	provider a reimbursement amount that is more than the amount the
67	67	issuer pays a nonaffiliated provider for the same health care
68	68	service.
69	69	(c) This section does not apply to value-based or capitation
70	70	reimbursement arrangements.
71	71	Sec. 1462.005. PROHIBITION ON CERTAIN COMMUNICATIONS. (a)
72	72	A health benefit plan issuer may not encourage or direct a patient
73	73	to use the issuer's affiliated provider through any oral or written
74	74	communication, including:
75	75	(1) online messaging regarding the provider; or
76	76	(2) patient- or prospective patient-specific
77	77	advertising, marketing, or promotion of the provider.
78	78	(b) This section does not prohibit a health benefit plan
79	79	issuer from encouraging or directing a patient to use an affiliated
80	80	provider that:
81	81	(1) accepts a reimbursement rate that is lower than
82	82	the rate a nonaffiliated provider would charge;
83	83	(2) is reimbursed by a health benefit plan issuer
84	84	through a risk-sharing or capitation arrangement; or
85	85	(3) is tiered against other providers based on
86	86	value-based quality metrics.
87	87	Sec. 1462.006. PROHIBITION ON CERTAIN REFERRALS AND
88	88	SOLICITATIONS. (a) A health benefit plan issuer may not require a
89	89	patient to use the issuer's affiliated provider for the patient to
90	90	receive the maximum benefit for the service under the patient's
91	91	health benefit plan.
92	92	(b) A health benefit plan issuer may not offer or implement
93	93	a health benefit plan that requires or induces a patient to use the
94	94	issuer's affiliated provider, including by providing for reduced
95	95	cost-sharing if the patient uses the affiliated provider.
96	96	(c) A health benefit plan issuer may not solicit a patient
97	97	or prescriber to transfer a patient's prescription to the issuer's
98	98	affiliated provider.
99	99	(d) This section does not prohibit a health benefit plan
100	100	issuer from soliciting or inducing a patient to use an affiliated
101	101	provider that:
102	102	(1) accepts a reimbursement rate that is lower than
103	103	the rate a nonaffiliated provider would charge;
104	104	(2) is reimbursed by a health benefit plan issuer
105	105	through a risk-sharing or capitation arrangement; or
106	106	(3) is tiered against other providers based on
107	107	value-based quality metrics.
108	108	SECTION 2. Chapter 1462, Insurance Code, as added by this
109	109	Act, applies only to a health benefit plan delivered, issued for
110	110	delivery, or renewed on or after January 1, 2026.
111	111	SECTION 3. This Act takes effect September 1, 2025.