Tex.
Ins. Code Section 1458.001
General Definitions
(1)
“Affiliate” means a person who, directly or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with another person.(1-a)
“Anti-steering clause” means a provision in a provider network contract that restricts the ability of a general contracting entity to encourage an enrollee to obtain a health care service from a competitor of the provider, including offering incentives to encourage enrollees to use specific providers.(1-b)
“Anti-tiering clause” means a provision in a provider network contract that:(A)
restricts the ability of a general contracting entity to introduce or modify a tiered network plan or assign providers into tiers; or(B)
requires a general contracting entity to place all members of a provider in the same tier of a tiered network plan.(2)
“Contracting entity” means a person who:(A)
enters into a direct contract with a provider for the delivery of health care services to covered individuals; and(B)
in the ordinary course of business establishes a provider network or networks for access by another party.(3)
“Covered individual” means an individual who is covered under a health benefit plan.(4)
“Express authority” means a provider’s consent that is obtained through separate signature lines for each line of business.(4-a)
“Gag clause” means a provision in a provider network contract that restricts the ability of a general contracting entity or provider to disclose:(A)
price or quality information, including the allowed amount, negotiated rates or discounts, fees for services, or other claim-related financial obligations included in the contract, to a governmental entity as authorized by law or its contractors or agents, an enrollee, a treating provider of an enrollee, a plan sponsor, or potential eligible enrollees and plan sponsors; or(B)
out-of-pocket costs to an enrollee.(4-b)
“General contracting entity” means a person who enters into a direct contract with a provider for the delivery of health care services to covered individuals regardless of whether the person, in the ordinary course of business, establishes a provider network for access by another party. The term does not include a health care provider or facility unless the provider or facility is entering into the contract in the provider’s or facility’s role as a health benefit plan.(5)
“Health care services” means services provided for the diagnosis, prevention, treatment, or cure of a health condition, illness, injury, or disease.(5-a)
“Most favored nation clause” means a provision in a provider network contract that:(A)
prohibits or grants an option to prohibit:(i)
a provider from contracting with another general contracting entity to provide health care services at a lower rate; or(ii)
a general contracting entity from contracting with another provider to provide health care services at a higher rate;(B)
requires or grants an option to require:(i)
a provider to accept a lower rate for health care services if the provider agrees with another general contracting entity to accept a lower rate for the services; or(ii)
a general contracting entity to pay a higher rate for health care services if the entity agrees with another provider to pay a higher rate for the services;(C)
requires or grants an option to require termination or renegotiation of an existing provider network contract if:(i)
a provider agrees with another general contracting entity to accept a lower rate for providing health care services; or(ii)
a general contracting entity agrees with a provider to pay a higher rate for health care services; or(D)
requires:(i)
a provider to disclose the provider’s contractual reimbursement rates with other general contracting entities; or(ii)
a general contracting entity to disclose the general contracting entity’s contractual reimbursement rates with other providers.(6)
“Person” has the meaning assigned by Section 823.002 (Definitions).(7)
(A) “Provider” means:(i)
an advanced practice nurse;(ii)
an optometrist;(iii)
a therapeutic optometrist;(iv)
a physician;(v)
a physician assistant;(vi)
a professional association composed solely of physicians, optometrists, or therapeutic optometrists;(vii)
a single legal entity authorized to practice medicine owned by two or more physicians;(viii)
a nonprofit health corporation certified by the Texas Medical Board under Chapter 162 (Regulation of Practice of Medicine), Occupations Code;(ix)
a partnership composed solely of physicians, optometrists, or therapeutic optometrists;(x)
a physician-hospital organization that acts exclusively as an administrator for a provider to facilitate the provider’s participation in health care contracts; or(xi)
an institution that is licensed under Chapter 241 (Hospitals), Health and Safety Code.(B)
“Provider” does not include a physician-hospital organization that leases or rents the physician-hospital organization’s network to another party.(8)
“Provider network contract” means a contract between a contracting entity and a provider for the delivery of, and payment for, health care services to a covered individual.
Source:
Section 1458.001 — General Definitions, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1458.htm#1458.001 (accessed May 18, 2024).
