bill for bundled surgery pricing in the state plan

The text as introduced · 1,175 words

89R3370 SCL-D

By: Gates
H.B. No. 1225

A BILL TO BE ENTITLED

AN ACT

relating to the establishment of a bundled-pricing program to

reduce certain health care costs in the state employees group

benefits program.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Chapter 1551, Insurance Code, is amended by

adding Subchapter K to read as follows:

SUBCHAPTER K. BUNDLED-PRICING PROGRAM

Sec. 1551.501. DEFINITIONS. In this subchapter:

(1) "Facility-based provider" has the meaning

assigned by Section 1551.229.

(2) "Program" means the bundled-pricing program

developed under this subchapter.

Sec. 1551.502. BUNDLED-PRICING PROGRAM. (a) The board of

trustees shall develop a cost-positive bundled-pricing program for

health benefit plans provided under the group benefits program.

(b) The program must be designed to reduce health care costs

in the group benefits program by contracting with a health care

facility, physician, or health care provider at a consolidated rate

for an inpatient or outpatient surgery procedure that is a covered

health care or medical service under a health benefit plan provided

under the group benefits program.

(c) A consolidated rate described by Subsection (b) must

include all fees related to the covered surgery procedure,

including fees for a health care facility, physician, health care

provider, laboratory, anesthesia, perioperative service,

prescription drug, or pharmacy service.

(d) The board of trustees shall contract with a third-party

administrator to administer the program. The program administrator

may be independent from the administrator of a health benefit plan

under the group benefits program.

Sec. 1551.503. PARTICIPATION; COST-SHARING OBLIGATION.

(a) A participant may have only an inpatient or outpatient surgery

procedure under the program.

(b) Except as provided by Subsection (c), the board of

trustees or a participating health care facility, physician, or

health care provider may not require a participant to pay a

deductible, copayment, coinsurance, or other cost-sharing

obligation for a covered surgery procedure provided under the

program.

(c) The board of trustees may require a participant in the

state consumer-directed health plan established under Section

1551.452 to meet the participant's deductible before the plan pays

for a covered surgery procedure provided under the program.

Sec. 1551.504. PROVIDER PARTICIPATION. (a) A health care

facility, physician, or health care provider is not required to

participate in the program. To participate, a health care

facility, physician, or health care provider must voluntarily and

expressly agree in writing to participate.

(b) A health care facility may not directly or indirectly:

(1) coerce a facility-based provider or physician to

participate in the program or accept a lower rate for an inpatient

or outpatient surgery procedure;

(2) condition a physician's staff membership or

privileges on the physician's participation in the program;

(3) consider a physician's participation or lack of

participation in the program in credentialing the physician;

(4) offer preferential scheduling to a participating

physician as compared to a physician who elects not to participate;

or

(5) terminate or otherwise penalize a physician or

health care provider for an election to not participate in the

program.

(c) The board of trustees, a health benefit plan, an

administrator of a health benefit plan provided under the group

program, or a health benefit plan issuer may not directly or

indirectly:

(1) coerce a health care facility, physician, or

health care provider to participate in the program;

(2) condition any plan participation on participation

in the program; or

(3) terminate or otherwise penalize a health care

facility, physician, or health care provider for electing not to

participate in the program.

Sec. 1551.505. PROCEDURE APPROVAL. (a) Before scheduling

a procedure under the program, a participating health care

facility, physician, or health care provider must apply for

approval from the program administrator in the form and manner

prescribed by the board of trustees.

(b) The approval application must include the consolidated

rate for the procedure and any other information determined

necessary by the program administrator.

(c) In determining whether to approve a procedure under this

section, the program administrator shall:

(1) ensure that the quality of care is comparable to

the care provided by a network provider for a health benefit plan

under the group benefits program;

(2) ensure that the procedure's cost is lower than the

procedure's cost if performed outside of the program; and

(3) if there is not a quality differential and

multiple health care facilities, physicians, or health care

providers apply to perform the same procedure for a participant,

consider the procedure's consolidated rate and the time the

procedure will be performed as the most important factors.

Sec. 1551.506. PAYMENT. (a) The board of trustees shall

ensure that a participating health care facility, physician, or

health care provider receives payment for a covered surgery

procedure not later than the 30th day after the date the program

administrator receives a claim for the procedure that includes, at

a minimum, each current procedural terminology code associated with

the bundled procedure and each ICD-10 code associated with the

patient.

(b) The program must include the methods by which payments

are allocated among a participating health care facility,

physician, or health care provider. If the consolidated bundled

payment is to be paid to an entity for further distribution to other

participating health care facilities, physicians, or health care

providers, the entity receiving the consolidated payment must be a

physician-led organization and have contracting authority on

behalf of the other participating facilities, physicians, and

providers.

(c) A participating health care facility, physician, or

health care provider may submit a request for payment to the

administrator for unanticipated services required to be provided

while performing a procedure under the program. The request must

include information on the reason the services were required.

Sec. 1551.507. BUNDLED-PRICING DISCLOSURE. (a) A

participating health care facility, physician, or health care

provider shall provide a written disclosure to a participant or the

participant's representative of the consolidated rate for a

procedure provided under the program before scheduling the

procedure.

(b) A health care facility, physician, or health care

provider that participates in the program may disclose a

consolidated rate for an inpatient or outpatient surgery procedure

on the facility's, physician's, or provider's Internet website and

marketing materials.

Sec. 1551.508. PUBLICATION OF INFORMATION. The board of

trustees shall publish information on the program, including a list

of participating health care facilities, physicians, and health

care providers and the consolidated rates offered by each

participating facility, physician, and provider, on the Employees

Retirement System of Texas website.

Sec. 1551.509. UNAUTHORIZED PRACTICE OF MEDICINE

PROHIBITED. This subchapter may not be construed to authorize:

(1) a lay person or entity to supervise or otherwise

control the practice of medicine as prohibited under Subtitle B,

Title 3, Occupations Code;

(2) a person or entity to engage in the unauthorized

practice of medicine in this state;

(3) a person or entity to misrepresent that the person

or entity is entitled to practice medicine; or

(4) a violation of Section 155.001, 155.003, 157.001,

164.052, or 165.156, Occupations Code.

Sec. 1551.510. RULEMAKING. The board of trustees may adopt

rules as necessary to implement this subchapter.

SECTION 2. This Act takes effect September 1, 2025.