Tex.
Ins. Code Section 1458.101
Contract Requirements
(a)
In this section, the following are each considered a single separate line of business:(1)
preferred provider benefit plans covering individuals and groups;(2)
exclusive provider benefit plans covering individuals and groups;(3)
health maintenance organization plans covering individuals and groups;(4)
Medicare Advantage or similar plans issued in connection with a contract with the Centers for Medicare and Medicaid Services;(5)
Medicaid managed care; and(6)
the state child health plan established under Chapter 62 (Child Health Plan for Certain Low-income Children), Health and Safety Code, or the comparable plan under Chapter 63 (Health Benefits Plan for Certain Children), Health and Safety Code.(b)
A contracting entity may not sell, lease, or otherwise transfer information regarding the payment or reimbursement terms of the provider network contract without the express authority of and prior adequate notification to the provider. The prior adequate notification may be provided in the written format specified by a provider network contract subject to this chapter.(c)
A contracting entity may not provide a person access to health care services or contractual discounts under a provider network contract unless the provider network contract specifically states that the contracting entity may contract with a person to provide access to the contracting entity’s rights and responsibilities under the provider network contract.(d)
The provider network contract must require that on the request of the provider, the contracting entity will provide information necessary to determine whether a particular person has been authorized to access the provider’s health care services and contractual discounts.(e)
To be enforceable against a provider, a provider network contract, including the lines of business described by Subsections (a) and (f), must also specify or reference a separate fee schedule for each such line of business. The separate fee schedule may describe specific services or procedures that the provider will deliver along with a corresponding payment, may describe a methodology for calculating payment based on a published fee schedule, or may describe payment in any other reasonable manner that specifies a definite payment for services. The fee information may be provided by any reasonable method, including electronically.(f)
The commissioner may, by rule, add additional lines of business for which express authority is required.(g)
A provider may not:(1)
offer to a general contracting entity a written provider network contract that includes an anti-steering, anti-tiering, gag, or most favored nation clause;(2)
enter into a provider network contract that includes an anti-steering, anti-tiering, gag, or most favored nation clause; or(3)
amend or renew an existing provider network contract previously entered into with a general contracting entity so that the contract as amended or renewed adds or retains an anti-steering, anti-tiering, gag, or most favored nation clause.(h)
Any provision in a provider network contract that is an anti-steering, anti-tiering, gag, or most favored nation clause is void and unenforceable. The remaining provisions in the provider network contract remain in effect and are enforceable.(i)
A health benefit plan issuer that encourages an enrollee to obtain a health care service from a particular provider, including offering incentives to encourage enrollees to use specific providers, or that introduces or modifies a tiered network plan or assigns providers into tiers has a fiduciary duty to the enrollee or policyholder to engage in that conduct only for the primary benefit of the enrollee or policyholder.
Source:
Section 1458.101 — Contract Requirements, https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1458.htm#1458.101 (accessed May 18, 2024).
