Bill Text: TX HB3098 | 2023-2024 | 88th Legislature | Introduced
Bill Title: Relating to prohibited conduct of a health benefit plan issuer in relation to affiliated and nonaffiliated providers.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2023-04-04 - Left pending in committee [HB3098 Detail]
Download: Texas-2023-HB3098-Introduced.html
| 88R2395 CJD-F | ||
| By: A. Johnson of Harris | H.B. No. 3098 | |
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| 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. (a) 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. | ||
| (b) Notwithstanding any other law, this chapter applies to: | ||
| (1) a small employer health benefit plan subject to | ||
| Chapter 1501, including coverage provided through a health group | ||
| cooperative under Subchapter B of that chapter; | ||
| (2) a standard health benefit plan issued under | ||
| Chapter 1507; | ||
| (3) health benefits provided by or through a church | ||
| benefits board under Subchapter I, Chapter 22, Business | ||
| Organizations Code; | ||
| (4) group health coverage made available by a school | ||
| district in accordance with Section 22.004, Education Code; | ||
| (5) a regional or local health care program operated | ||
| under Section 75.104, Health and Safety Code; and | ||
| (6) a self-funded health benefit plan sponsored by a | ||
| professional employer organization under Chapter 91, Labor Code. | ||
| 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 533, 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. | ||
| Sec. 1462.005. PROHIBITION ON CERTAIN COMMUNICATIONS. 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. | ||
| 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. | ||
| 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, 2024. | ||
| SECTION 3. This Act takes effect September 1, 2023. | ||
