bill letting health plans steer patients with lower copays

The text as introduced · 1,172 words

89R7882 DNC-F

By: Frank
H.B. No. 1959

A BILL TO BE ENTITLED

AN ACT

relating to certain practices of health benefit plan issuers to

encourage the use of certain physicians and health care providers

and rank physicians.

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

SECTION 1. Subchapter I, Chapter 843, Insurance Code, is

amended by adding Section 843.322 to read as follows:

Sec. 843.322. INCENTIVES TO USE CERTAIN PHYSICIANS OR

PROVIDERS. (a) A health maintenance organization may provide

incentives for enrollees to use certain physicians or providers

through modified deductibles, copayments, coinsurance, or other

cost-sharing provisions.

(b) A health maintenance organization that encourages an

enrollee to obtain a health care service from a particular

physician or provider, including offering incentives to encourage

enrollees to use specific physicians or providers, or that

introduces or modifies a tiered network plan or assigns physicians

or providers into tiers, has a fiduciary duty to the enrollee or

group contract holder to engage in that conduct only for the primary

benefit of the enrollee or group contract holder.

SECTION 2. Section 1301.0045(a), Insurance Code, is amended

to read as follows:

(a) Except as provided by Sections [ Section ] 1301.0046 and

1301.0047 , this chapter may not be construed to limit the level of

reimbursement or the level of coverage, including deductibles,

copayments, coinsurance, or other cost-sharing provisions, that

are applicable to preferred providers or, for plans other than

exclusive provider benefit plans, nonpreferred providers.

SECTION 3. Subchapter A, Chapter 1301, Insurance Code, is

amended by adding Section 1301.0047 to read as follows:

Sec. 1301.0047. INCENTIVES TO USE CERTAIN PHYSICIANS OR

HEALTH CARE PROVIDERS. (a) An insurer may provide incentives for

insureds to use certain physicians or health care providers through

modified deductibles, copayments, coinsurance, or other

cost-sharing provisions.

(b) An insurer that encourages an insured to obtain a health

care service from a particular physician or health care provider,

including offering incentives to encourage insureds to use specific

physicians or providers, or that introduces or modifies a tiered

network plan or assigns physicians or providers into tiers, has a

fiduciary duty to the insured or policyholder to engage in that

conduct only for the primary benefit of the insured or

policyholder.

SECTION 4. Section 1460.003, Insurance Code, is amended by

amending Subsection (a) and adding Subsection (a-1) to read as

follows:

(a) A health benefit plan issuer, including a subsidiary or

affiliate, may not rank physicians or [ , ] classify physicians into

tiers based on performance[ , or publish physician-specific

information that includes rankings, tiers, ratings, or other

comparisons of a physician's performance against standards,

measures, or other physicians, ] unless:

(1) the standards used by the health benefit plan

issuer to rank or classify are propagated or developed by an

organization designated by the commissioner through rules adopted

under Section 1460.005;

(2) the ranking, comparison, or evaluation:

(A) is disclosed to each affected physician at

least 45 days before the date the ranking, comparison, or

evaluation is released, published, or distributed to enrollees by

the health benefit plan issuer; and

(B) identifies which products or networks

offered by the health benefit plan issuer the ranking, comparison,

or evaluation will be used for; and

(3) each affected physician is given an easy-to-use

process to identify discrepancies between the standards and the

ranking, comparison, or evaluation as propagated by the health

benefit plan issuer [ the standards used by the health benefit plan

issuer conform to nationally recognized standards and guidelines as

required by rules adopted under Section 1460.005;

[ (2) the standards and measurements to be used by the

health benefit plan issuer are disclosed to each affected physician

before any evaluation period used by the health benefit plan

issuer; and

[ (3) each affected physician is afforded, before any

publication or other public dissemination, an opportunity to

dispute the ranking or classification through a process that, at a

minimum, includes due process protections that conform to the

following protections:

[ (A) the health benefit plan issuer provides at

least 45 days' written notice to the physician of the proposed

rating, ranking, tiering, or comparison, including the

methodologies, data, and all other information utilized by the

health benefit plan issuer in its rating, tiering, ranking, or

comparison decision;

[ (B) in addition to any written fair

reconsideration process, the health benefit plan issuer, upon a

request for review that is made within 30 days of receiving the

notice under Paragraph (A), provides a fair reconsideration

proceeding, at the physician's option:

[ (i) by teleconference, at an agreed upon

time; or

[ (ii) in person, at an agreed upon time or

between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday;

[ (C) the physician has the right to provide

information at a requested fair reconsideration proceeding for

determination by a decision-maker, have a representative

participate in the fair reconsideration proceeding, and submit a

written statement at the conclusion of the fair reconsideration

proceeding; and

[ (D) the health benefit plan issuer provides a

written communication of the outcome of a fair reconsideration

proceeding prior to any publication or dissemination of the rating,

ranking, tiering, or comparison. The written communication must

include the specific reasons for the final decision ].

(a-1) If a physician submits information to a health benefit

plan issuer under Subsection (a)(3) sufficient to establish a

discrepancy, the health benefit plan issuer must remedy the

discrepancy by the later of:

(1) publication; or

(2) the 30th day after the date the health benefit plan

issuer receives the information.

SECTION 5. Section 1460.005(c), Insurance Code, is amended

to read as follows:

(c) In adopting rules under this section, the commissioner

may only designate [ shall consider the standards, guidelines, and

measures prescribed by nationally recognized ] organizations that

meet the following requirements:

(1) the prescribing organization is bona fide and

unbiased toward or against any medical provider;

(2) the standards to be used in rankings, comparisons,

or evaluations:

(A) are nationally recognized, or based on

expert-provider consensus or leading clinical evidence-based

scholarship;

(B) have a publicly transparent methodology; and

(C) if based on clinical outcomes, are

risk-adjusted; and

(3) the prescribing organization has an easy-to-use

process by which a medical provider may report data, evidentiary,

factual, or mathematical errors for prompt investigation and, if

appropriate, correction [ establish or promote guidelines and

performance measures emphasizing quality of health care, including

the National Quality Forum and the AQA Alliance. If neither the

National Quality Forum nor the AQA Alliance has established

standards or guidelines regarding an issue, the commissioner shall

consider the standards, guidelines, and measures prescribed by the

National Committee on Quality Assurance and other similar national

organizations. If neither the National Quality Forum, nor the AQA

Alliance, nor other national organizations have established

standards or guidelines regarding an issue, the commissioner shall

consider standards, guidelines, and measures based on other bona

fide nationally recognized guidelines, expert-based physician

consensus quality standards, or leading objective clinical

evidence and scholarship ].

SECTION 6. This Act takes effect September 1, 2025.