89R13255 SCF-F     By: Vo H.B. No. 4102       A BILL TO BE ENTITLED   AN ACT   relating to prohibited conduct of a health benefit plan issuer in   relation to affiliated and nonaffiliated providers.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Subtitle F, Title 8, Insurance Code, is amended   by adding Chapter 1462 to read as follows:   CHAPTER 1462. AFFILIATED PROVIDERS          Sec. 1462.001.  DEFINITIONS. In this chapter:                (1)  "Affiliated provider" means a health care provider   that directly, or indirectly through one or more intermediaries,   controls, is controlled by, or is under common control with a health   benefit plan issuer.                (2)  "Nonaffiliated provider" means a health care   provider that does not directly, or indirectly through one or more   intermediaries, control and is not controlled by or under common   control with a health benefit plan issuer.          Sec. 1462.002.  APPLICABILITY OF CHAPTER. This chapter   applies only to a health benefit plan that provides benefits for   medical or surgical expenses incurred as a result of a health   condition, accident, or sickness, including an individual, group,   blanket, or franchise insurance policy or insurance agreement, a   group hospital service contract, or an individual or group evidence   of coverage or similar coverage document that is offered by:                (1)  an insurance company;                (2)  a group hospital service corporation operating   under Chapter 842;                (3)  a health maintenance organization operating under   Chapter 843;                (4)  an approved nonprofit health corporation that   holds a certificate of authority under Chapter 844;                (5)  a multiple employer welfare arrangement that holds   a certificate of authority under Chapter 846;                (6)  a stipulated premium company operating under   Chapter 884;                (7)  a fraternal benefit society operating under   Chapter 885;                (8)  a Lloyd's plan operating under Chapter 941; or                (9)  an exchange operating under Chapter 942.          Sec. 1462.003.  EXCEPTION TO APPLICABILITY OF CHAPTER. This   chapter does not apply to an issuer, provider, or administrator of   health benefits under:                (1)  the state Medicaid program, including the Medicaid   managed care program operated under Chapter 540, Government Code;                (2)  the child health plan program under Chapter 62,   Health and Safety Code;                (3)  a basic coverage plan under Chapter 1551;                (4)  a basic plan under Chapter 1575;                (5)  a coverage plan under Chapter 1579;                (6)  a plan providing basic coverage under Chapter   1601; or                (7)  a workers' compensation insurance policy or other   form of providing medical benefits under Title 5, Labor Code.           Sec. 1462.004.  REIMBURSEMENT OF AFFILIATED AND   NONAFFILIATED PROVIDERS. (a)  A health benefit plan issuer may not   offer a higher reimbursement rate to a health care practitioner who   is a member of a nonaffiliated provider based on a condition that   the practitioner agrees to join an affiliated provider.          (b)  A health benefit plan issuer may not pay an affiliated   provider a reimbursement amount that is more than the amount the   issuer pays a nonaffiliated provider for the same health care   service.          (c)  This section does not apply to value-based or capitation   reimbursement arrangements.          Sec. 1462.005.  PROHIBITION ON CERTAIN COMMUNICATIONS. (a)     A health benefit plan issuer may not encourage or direct a patient   to use the issuer's affiliated provider through any oral or written   communication, including:                (1)  online messaging regarding the provider; or                (2)  patient- or prospective patient-specific   advertising, marketing, or promotion of the provider.          (b)  This section does not prohibit a health benefit plan   issuer from encouraging or directing a patient to use an affiliated   provider that:                (1)  accepts a reimbursement rate that is lower than   the rate a nonaffiliated provider would charge;                (2)  is reimbursed by a health benefit plan issuer   through a risk-sharing or capitation arrangement; or                (3)  is tiered against other providers based on   value-based quality metrics.          Sec. 1462.006.  PROHIBITION ON CERTAIN REFERRALS AND   SOLICITATIONS. (a)  A health benefit plan issuer may not require a   patient to use the issuer's affiliated provider for the patient to   receive the maximum benefit for the service under the patient's   health benefit plan.          (b)  A health benefit plan issuer may not offer or implement   a health benefit plan that requires or induces a patient to use the   issuer's affiliated provider, including by providing for reduced   cost-sharing if the patient uses the affiliated provider.          (c)  A health benefit plan issuer may not solicit a patient   or prescriber to transfer a patient's prescription to the issuer's   affiliated provider.          (d)  This section does not prohibit a health benefit plan   issuer from soliciting or inducing a patient to use an affiliated   provider that:                (1)  accepts a reimbursement rate that is lower than   the rate a nonaffiliated provider would charge;                (2)  is reimbursed by a health benefit plan issuer   through a risk-sharing or capitation arrangement; or                (3)  is tiered against other providers based on   value-based quality metrics.          SECTION 2.  Chapter 1462, Insurance Code, as added by this   Act, applies only to a health benefit plan delivered, issued for   delivery, or renewed on or after January 1, 2026.          SECTION 3.  This Act takes effect September 1, 2025.