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Texas Senate Bill SB884

Texas 2025 - 89th Regular

Texas Senate Bill SB884 Compare Versions

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1+89R8002 SCL-D
12 By: Kolkhorst S.B. No. 884
2- (In the Senate - Filed January 23, 2025; February 13, 2025,
3- read first time and referred to Committee on Health & Human
4- Services; April 14, 2025, reported adversely, with favorable
5- Committee Substitute by the following vote: Yeas 9, Nays 0;
6- April 14, 2025, sent to printer.)
7-Click here to see the committee vote
8- COMMITTEE SUBSTITUTE FOR S.B. No. 884 By: Kolkhorst
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137 A BILL TO BE ENTITLED
148 AN ACT
15- relating to establishment of a shared savings program for health
16- maintenance organizations and preferred provider benefit plans.
9+ relating to establishment of a shared savings program for certain
10+ managed care plans.
1711 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1812 SECTION 1. Subtitle C, Title 8, Insurance Code, is amended
1913 by adding Chapter 1276 to read as follows:
2014 CHAPTER 1276. SHARED SAVINGS PROGRAM
2115 SUBCHAPTER A. GENERAL PROVISIONS
2216 Sec. 1276.001. DEFINITIONS. In this chapter:
23- (1) "Direct pay provider" means a health care provider
24- of any health care service or supply that will accept direct payment
25- for a health care service or supply from a patient instead of
26- processing a claim for payment for the service or supply through the
27- patient's health care plan or preferred provider benefit plan.
28- (2) "Health care provider" means a health care
17+ (1) "Health care provider" means a health care
2918 practitioner or health care facility that provides health care
3019 services or supplies under a license, certificate, registration, or
3120 similar authorization issued by this state.
32- (3) "Program" means a shared savings program
21+ (2) "Managed care plan" means a health benefit plan
22+ under which health care services or supplies are provided to
23+ enrollees through contracts with health care providers and that
24+ requires enrollees to use contracting providers or that provides a
25+ different level of coverage for enrollees who use contracting
26+ providers.
27+ (3) "Out-of-network provider" means a health care
28+ provider of any health care service or supply that does not have a
29+ contract under an enrollee's health benefit plan.
30+ (4) "Program" means the shared savings program
3331 established under this chapter.
34- Sec. 1276.002. APPLICABILITY OF CHAPTER. This chapter
35- applies only to medically necessary nonemergency health care
36- services or supplies covered under:
37- (1) a health care plan provided by a health
38- maintenance organization operating under Chapter 843; or
32+ Sec. 1276.002. APPLICABILITY OF CHAPTER. (a) This chapter
33+ applies only to nonemergency health care services or supplies
34+ covered under a managed care plan.
35+ (b) This chapter applies only to the following health
36+ benefit plans:
37+ (1) a health benefit plan provided by a health
38+ maintenance organization operating under Chapter 843;
3939 (2) a preferred provider benefit plan provided under
40- Chapter 1301.
40+ Chapter 1301; or
41+ (3) a basic coverage plan provided under Chapter 1551.
42+ (c) Notwithstanding any other law, this chapter applies to
43+ an administrator of a health benefit plan described by this
44+ section.
4145 Sec. 1276.003. RULES. The commissioner may adopt rules
4246 necessary to implement this chapter.
4347 SUBCHAPTER B. PROGRAM REQUIREMENTS
44- Sec. 1276.051. PROGRAM REQUIRED. (a) A health maintenance
45- organization or insurer to which this chapter applies shall
48+ Sec. 1276.051. PROGRAM REQUIRED. (a) A health benefit plan
49+ issuer or administrator to which this chapter applies shall
4650 establish a shared savings program in accordance with this chapter.
47- (b) A health maintenance organization or insurer shall
48- provide written notice to its enrollees or insureds of the program.
49- (c) An insurer may not require a different procedure for an
50- insured to claim a shared savings incentive payment under this
51- chapter than the procedures established by the insurer under
52- Section 1301.140.
51+ (b) A health benefit plan issuer or administrator shall
52+ provide written notice to its enrollees of the program.
5353 Sec. 1276.052. AVERAGE CONTRACTED RATE DISCLOSURE. (a) As
54- part of the program, a health maintenance organization or insurer
55- shall establish a publicly available Internet website for any
56- person to view the average contracted rate paid by the health
57- maintenance organization or insurer under a health care plan or
58- preferred provider benefit plan to a health care provider in the
59- plan's provider network for a particular health care service or
60- supply in the preceding 12 months. The health maintenance
61- organization or insurer shall update the average contracted rate at
62- least once per month.
63- (b) As part of the program, a health maintenance
64- organization or insurer shall establish and operate a toll-free
65- telephone number for an enrollee or insured to request disclosure
66- of the average contracted rate paid under the enrollee's health
67- care plan or the insured's preferred provider benefit plan to a
54+ part of the program, a health benefit plan issuer or administrator
55+ shall establish and operate a toll-free telephone number and
56+ publicly accessible Internet website for a plan enrollee to request
57+ disclosure of the average contracted rate paid under the plan to a
6858 health care provider in the plan's provider network for a
6959 particular health care service or supply in the preceding 12
7060 months.
71- (c) An insurer may use a system described by Subsection (a)
72- or (b) for the purposes of Section 1301.140.
73- (d) A health maintenance organization or insurer shall
74- disclose to the enrollee or insured the rate the enrollee or insured
75- requested under Subsection (b).
76- Sec. 1276.053. PARTICIPATION USING DIRECT PAY PROVIDER.
77- (a) For purposes of enrollee or insured eligibility for a shared
78- savings incentive payment under Section 1276.054, a health care
79- provider may be considered a direct pay provider if the health care
80- provider:
81- (1) publishes the final price that the provider would
82- accept for a health care service or supply eligible under a program
83- for each of the 100 most common nonemergency health care services or
84- supplies offered by the provider and that reflects the enrollee's
85- or insured's final out-of-pocket cost for the service or supply; or
86- (2) provides an enrollee or insured on request a
87- direct pay price with a written estimate of the final charge for a
88- proposed health care service or supply eligible under the
89- enrollee's or insured's program that includes prices for all
90- services or supplies associated with the proposed service or supply
91- and that reflects the enrollee's or insured's final out-of-pocket
92- cost associated with the proposed service or supply.
93- (b) A facility to which Chapter 324, Health and Safety Code,
94- applies that provides an estimate of the facility's charges for a
95- proposed service in accordance with Section 324.101(d), Health and
96- Safety Code, satisfies Subsection (a)(2) with respect to that
97- service.
98- (c) An enrollee or insured may request a direct pay price
99- described by Subsection (a)(2) from any health care provider,
100- regardless of whether the provider has published the information
101- described by Subsection (a)(1), and the enrollee's or insured's
102- decision to obtain a health care service or supply from that
103- provider does not affect the enrollee's or insured's eligibility
104- for a shared savings incentive payment under the enrollee's or
105- insured's program.
106- (d) A direct pay provider may provide assistance to an
107- enrollee or insured in filing paperwork or providing proof of care
108- or medical necessity in connection with the enrollee's or insured's
109- claim for reimbursement or a shared savings incentive payment under
110- this chapter.
111- Sec. 1276.054. SHARED SAVINGS INCENTIVE PAYMENT. (a) An
112- enrollee or insured who elects and receives a medically necessary
113- and covered health care service or supply from a direct pay provider
114- and pays an actual price less than the rate disclosed by the
115- enrollee's health maintenance organization or the insured's insurer
116- under Section 1276.052 is eligible for a shared savings incentive
117- payment under the enrollee's or insured's program.
118- (b) Except as provided by Subsection (c), a health
119- maintenance organization or insurer shall pay to an eligible
120- enrollee or insured a shared savings incentive payment equal to 50
121- percent of the difference between the disclosed rate and the actual
122- price paid to the direct pay provider, minus any applicable
123- deductible, copayment, or coinsurance.
124- (c) A health maintenance organization or insurer is not
125- required to pay an enrollee or insured a shared savings incentive
126- payment under Subsection (b) if:
127- (1) the amount of the shared savings incentive payment
128- would be less than $50; or
129- (2) both:
130- (A) the enrollee's or insured's total shared
131- savings incentive payments for the plan year exceed the greater of:
132- (i) $20,000; or
133- (ii) the enrollee's or insured's
134- deductibles and out-of-pocket maximum; and
135- (B) the health maintenance organization or
136- insurer has provided written notice to the enrollee or insured that
137- the enrollee or insured is not eligible for a shared savings
138- incentive payment for the remainder of the plan year.
139- (d) A health maintenance organization or insurer shall pay
140- an enrollee or insured under Subsection (b) not later than the 30th
141- day after the date on which the enrollee or insured submits a
142- program claim.
143- (e) A health maintenance organization or insurer may pay a
144- shared savings incentive payment through a cash payment or other
145- incentive or combination of incentives, including:
146- (1) a gift card;
147- (2) a deposit into a health reimbursement arrangement
148- or savings account;
149- (3) a premium reduction or rebate; and
150- (4) a cost-sharing reduction.
151- Sec. 1276.055. COST SHARING UNDER PROGRAM FOR PREFERRED
152- PROVIDER BENEFIT PLAN. (a) This section applies only to a
153- medically necessary health care service or supply that:
154- (1) is covered under a preferred provider benefit
155- plan; and
156- (2) an insured receives from a direct pay provider for
157- an amount that is less than the average contracted rate disclosed by
158- the insured's insurer under Section 1276.052.
159- (b) An insurer shall comply with the requirements of Section
160- 1301.140 to ensure that cost-sharing amounts paid by an insured for
161- a service or supply described by Subsection (a) are counted toward
162- the insured's in-network cost-sharing limits.
163- Sec. 1276.056. ACCOUNTING AND ADMINISTRATION FOR HEALTH
164- MAINTENANCE ORGANIZATION OR INSURER. (a) If required by the
165- federal government, a health maintenance organization or insurer
166- that pays total shared savings incentive payments in excess of $600
167- to an enrollee or insured during a calendar year shall issue to the
168- enrollee or insured an Internal Revenue Service Form 1099 not later
169- than January 31 of the following year.
170- (b) A health maintenance organization or insurer that pays
171- shared savings incentive payments under this chapter may apply to
172- the United States Department of Health and Human Services to
173- include the payments as incurred claims under 45 C.F.R. Section
174- 158.221(b)(8).
175- Sec. 1276.057. LIABILITY FOR UNFORESEEN CHARGE OVER
61+ (b) A health benefit plan issuer or administrator shall
62+ disclose to the enrollee the rate the enrollee requested under
63+ Subsection (a).
64+ Sec. 1276.053. HEALTH CARE PROVIDER ESTIMATE. An
65+ out-of-network provider shall, on an enrollee's request, provide
66+ the enrollee a written estimate of the final charge for a proposed
67+ health care service or supply eligible for the enrollee's program.
68+ The estimate must include all costs associated with the service or
69+ supply and reflect the enrollee's final out-of-pocket cost
70+ associated with the proposed service or supply.
71+ Sec. 1276.054. SHARED SAVINGS PAYMENT. (a) Except as
72+ provided by Subsection (b), if an enrollee who requests a
73+ disclosure under Section 1276.052 elects and receives a health care
74+ service or supply with an actual cost equal to an amount less than
75+ the rate disclosed under Section 1276.052, the health benefit plan
76+ issuer or administrator shall pay to the enrollee 50 percent of the
77+ difference between the disclosed rate and the actual cost, minus
78+ any applicable deductible, copayment, or coinsurance.
79+ (b) A health benefit plan issuer is not required to pay an
80+ enrollee under Subsection (a) if the difference described by that
81+ subsection is less than $50.
82+ (c) A health benefit plan issuer or administrator shall pay
83+ an enrollee under Subsection (a) not later than the 30th day after
84+ the date on which the enrollee submits a program claim.
85+ Sec. 1276.055. DEDUCTIBLES UNDER PROGRAM. (a) This section
86+ applies only to a health care service or supply for which an
87+ enrollee received:
88+ (1) a disclosure under Section 1276.052; and
89+ (2) an estimate under Section 1276.053 equal to an
90+ amount at least $50 less than the rate provided under the
91+ disclosure.
92+ (b) A health benefit plan issuer or administrator shall
93+ apply a deductible for a health care service or supply to which this
94+ section applies in an amount equivalent to the deductible applied
95+ to a network service or supply.
96+ Sec. 1276.056. LIABILITY FOR UNFORESEEN CHARGE OVER
17697 ESTIMATE. If the final charge for the health care service or supply
17798 described by Section 1276.055(a) is an amount greater than the
17899 amount estimated under Section 1276.053 due to unforeseen
179- circumstances, the enrollee or insured is liable for the difference
180- only if:
181- (1) before the enrollee or insured is billed, the
182- enrollee or insured agrees in writing to pay the additional amount;
183- and
184- (2) before receiving the service or supply, the
185- enrollee or insured receives written notice that the enrollee or
186- insured may be liable for charges resulting from unforeseen
187- circumstances.
100+ circumstances, the enrollee's health benefit plan issuer or
101+ administrator shall pay 95 percent of the difference not to exceed
102+ the allowed amount for the service or supply and the enrollee is
103+ responsible for the remaining difference.
188104 SECTION 2. Chapter 1276, Insurance Code, as added by this
189- Act, applies only to a health care plan or insurance policy
190- delivered, issued for delivery, or renewed on or after January 1,
191- 2026.
105+ Act, applies only to a health benefit plan delivered, issued for
106+ delivery, or renewed on or after January 1, 2026.
192107 SECTION 3. This Act takes effect September 1, 2025.
193- * * * * *