HB 4102 — Relating to prohibited conduct of a health benefit plan issuer in relation to affiliated and nonaffiliated providers.

Summary

Relating to prohibited conduct of a health benefit plan issuer in relation to affiliated and nonaffiliated providers.

Bill Text

AI-generated reading aid from the bill's amendatory text — verify against the official bill.

This bill amends the Texas statutes.

• 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 pro

  amended

Action History

1. March 27, 2025

   Referred to Insurance

2. March 27, 2025

   Read first time

3. March 07, 2025

   Filed

Sponsors

• Hubert Vo · Primary

Subjects