General definitions; Contract requirements; Contract access
See the bold text below:
Section. 1458.001. General Definitions. In this chapter:
Rental Networks
(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.
(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.
(5) “Health care services” means services provided for the diagnosis, prevention, treatment, or cure of a health condition, illness, injury, or disease.
(6) “Person” has the meaning assigned by Section 823.002.
(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, 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, 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.
Sections (1) through (8) may be accessed at https://law.justia.com/codes/texas/2022/insurance-code/title-8/subtitle-f/chapter-1458/subchapter-a/section-1458-001/. These sections (1) through (8) were not amended in 2023. However, in 2023, sections (1-a), (1-b), (4-a), (4-b) and (5-1) were added to Section 1458.001 by HB 711 (2023). See https://capitol.texas.gov/BillLookup/History.aspx?LegSess=88R&Bill=HB711.
(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.
(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.
Most favored nation
(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.
Rental Networks
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, Health and Safety Code, or the comparable plan under Chapter 63, 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.
Fee Schedules
(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.
Sections (a) through (f) were not amended in 2023. See https://law.justia.com/codes/texas/2021/insurance-code/title-8/subtitle-f/chapter-1458/subchapter-c/section-1458-101/. The following sections below, i.e., sections (g), (h), and (i) were added to section 1458.101 in 2023 by HB 711 (2023). See https://capitol.texas.gov/BillLookup/History.aspx?LegSess=88R&Bill=HB711
Most Favored Nation
(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.
Most Favored Nation
(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.
Rental Networks
Section 1458.102. Contract access.
(a) 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 person must comply with all applicable terms, limitations, and conditions of the provider network contract.
(b) For the purposes of this section, a contracting entity shall permit reasonable access, including electronic access, during business hours for the review of the provider network contract. The information may be used or disclosed only for the purposes of complying with the terms of the contract or state law.
See https://law.justia.com/codes/texas/2021/insurance-code/title-8/subtitle-f/chapter-1458/subchapter-c/