89R13255 SCF-F
By: Hughes S.B. No. 1156
A BILL TO BE ENTITLED
AN ACT
relating to prohibited conduct of a health benefit plan issuer in
relation to affiliated and nonaffiliated providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle F, Title 8, Insurance Code, is amended
by adding Chapter 1462 to read as follows:
CHAPTER 1462. AFFILIATED PROVIDERS
Sec. 1462.001. DEFINITIONS. In this chapter:
(1) "Affiliated provider" means a health care provider
that directly, or indirectly through one or more intermediaries,
controls, is controlled by, or is under common control with a health
benefit plan issuer.
(2) "Nonaffiliated provider" means a health care
provider that does not directly, or indirectly through one or more
intermediaries, control and is not controlled by or under common
control with a health benefit plan issuer.
Sec. 1462.002. APPLICABILITY OF CHAPTER. This chapter
applies only to a health benefit plan that provides benefits for
medical or surgical expenses incurred as a result of a health
condition, accident, or sickness, including an individual, group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, or an individual or group evidence
of coverage or similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885;
(8) a Lloyd's plan operating under Chapter 941; or
(9) an exchange operating under Chapter 942.
Sec. 1462.003. EXCEPTION TO APPLICABILITY OF CHAPTER. This
chapter does not apply to an issuer, provider, or administrator of
health benefits under:
(1) the state Medicaid program, including the Medicaid
managed care program operated under Chapter 540, Government Code;
(2) the child health plan program under Chapter 62,
Health and Safety Code;
(3) a basic coverage plan under Chapter 1551;
(4) a basic plan under Chapter 1575;
(5) a coverage plan under Chapter 1579;
(6) a plan providing basic coverage under Chapter
1601; or
(7) a workers' compensation insurance policy or other
form of providing medical benefits under Title 5, Labor Code.
Sec. 1462.004. REIMBURSEMENT OF AFFILIATED AND
NONAFFILIATED PROVIDERS. (a) A health benefit plan issuer may not
offer a higher reimbursement rate to a health care practitioner who
is a member of a nonaffiliated provider based on a condition that
the practitioner agrees to join an affiliated provider.
(b) A health benefit plan issuer may not pay an affiliated
provider a reimbursement amount that is more than the amount the
issuer pays a nonaffiliated provider for the same health care
service.
(c) This section does not apply to value-based or capitation
reimbursement arrangements.
Sec. 1462.005. PROHIBITION ON CERTAIN COMMUNICATIONS. (a)
A health benefit plan issuer may not encourage or direct a patient
to use the issuer's affiliated provider through any oral or written
communication, including:
(1) online messaging regarding the provider; or
(2) patient- or prospective patient-specific
advertising, marketing, or promotion of the provider.
(b) This section does not prohibit a health benefit plan
issuer from encouraging or directing a patient to use an affiliated
provider that:
(1) accepts a reimbursement rate that is lower than
the rate a nonaffiliated provider would charge;
(2) is reimbursed by a health benefit plan issuer
through a risk-sharing or capitation arrangement; or
(3) is tiered against other providers based on
value-based quality metrics.
Sec. 1462.006. PROHIBITION ON CERTAIN REFERRALS AND
SOLICITATIONS. (a) A health benefit plan issuer may not require a
patient to use the issuer's affiliated provider for the patient to
receive the maximum benefit for the service under the patient's
health benefit plan.
(b) A health benefit plan issuer may not offer or implement
a health benefit plan that requires or induces a patient to use the
issuer's affiliated provider, including by providing for reduced
cost-sharing if the patient uses the affiliated provider.
(c) A health benefit plan issuer may not solicit a patient
or prescriber to transfer a patient's prescription to the issuer's
affiliated provider.
(d) This section does not prohibit a health benefit plan
issuer from soliciting or inducing a patient to use an affiliated
provider that:
(1) accepts a reimbursement rate that is lower than
the rate a nonaffiliated provider would charge;
(2) is reimbursed by a health benefit plan issuer
through a risk-sharing or capitation arrangement; or
(3) is tiered against other providers based on
value-based quality metrics.
SECTION 2. Chapter 1462, Insurance Code, as added by this
Act, applies only to a health benefit plan delivered, issued for
delivery, or renewed on or after January 1, 2026.
SECTION 3. This Act takes effect September 1, 2025.