Relating to certain practices of health benefit plan issuers to encourage the use of certain physicians and health care providers and rank physicians.

BILL ANALYSIS

AUTHOR'S / SPONSOR'S STATEMENT OF INTENT

Currently, the Insurance Code prevents health insurance options that encourage patients to be smart shoppers.

Texas employers would like to be able to utilize health insurance plans for their employees that not only share basic information about physician prices but also how they meet nationally recognized quality of care standards. Employers that have used these types of flexible plans where they are allowed have been able to lower health care costs by five percent.

Health care price transparency is rapidly advancing, yet many patients still lack incentives to shop for lower cost, higher quality health care services and providers.

S.B. 926 modernizes the Insurance Code to allow health benefits that incentivize patients to make value-driven health care decisions.

As proposed, S.B. 926 amends current law relating to certain practices of health benefit plan issuers to encourage the use of certain physicians and health care providers and rank physicians.

RULEMAKING AUTHORITY

Rulemaking authority previously granted to the commissioner of insurance is modified in SECTION 5 (Section 1460.005, Insurance Code) of this bill.

SECTION BY SECTION ANALYSIS

SECTION 1. Amends Subchapter I, Chapter 843, Insurance Code, by adding Section 843.322, as follows:

Sec. 843.322. INCENTIVES TO USE CERTAIN PHYSICIANS OR PROVIDERS. (a) Authorizes a health maintenance organization (HMO) to provide incentives for enrollees to use certain physicians or providers through modified deductibles, copayments, coinsurance, or other cost-sharing provisions.

(b) Provides that a HMO 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. Amends Section 1301.0045(a), Insurance Code, to prohibit Chapter 1301 (Preferred Provider Benefit Plans), except as provided by Sections 1301.0046 (Coinsurance Requirements for Services of Nonpreferred Providers) and 1301.0047, from being 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, and to make a nonsubstantive change.

SECTION 3. Amends Subchapter A, Chapter 1301, Insurance Code, by adding Section 1301.0047, as follows:

Sec. 1301.0047. INCENTIVES TO USE CERTAIN PHYSICIANS OR HEALTH CARE PROVIDERS. (a) Authorizes an insurer to provide incentives for insureds to use certain physicians or health care providers through modified deductibles, copayments, coinsurance, or other cost-sharing provisions.

(b) Provides that 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. Amends Section 1460.003, Insurance Code, by amending Subsection (a) and adding Subsection (a-1), as follows:

(a) Prohibits a health benefit plan issuer, including a subsidiary or affiliate, from ranking physicians or classifying physicians into tiers based on performance 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 of insurance (commissioner) through rules adopted under Section 1460.005 (Rules; Standards);

(2) the ranking, comparison, or evaluation meets certain criteria; 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.

Deletes existing text prohibiting a health benefit plan issuer, including a subsidiary or affiliate, from publishing physician-specific information that includes rankings, tiers, ratings, or other comparisons of a physician's performance against standards, measures, or other physicians, unless certain criteria are met.

(a-1) Requires a health benefit plan issuer, if a physician submits information to the health benefit plan issuer under Subsection (a)(3) sufficient to establish a discrepancy, to remedy the discrepancy by the later of publication or the 30th day after the date the health benefit plan issuer receives the information.

SECTION 5. Amends Section 1460.005(c), Insurance Code, as follows:

(c) Provides that, in adopting rules under this section, the commissioner is authorized to only designate organizations that meet certain requirements. Deletes existing text requiring the commissioner, in adopting rules under this section, to consider the standards, guidelines, and measures prescribed by nationally recognized organizations that establish or promote guidelines and performance measures emphasizing quality of health care, including the National Quality Forum and the AQA Alliance. Deletes existing text requiring the commissioner, if neither the National Quality Forum nor the AQA Alliance has established standards or guidelines regarding an issue, to consider the standards, guidelines, and measures prescribed by the National Committee on Quality Assurance and other similar national organizations. Deletes existing text requiring the commissioner, if neither the National Quality Forum, nor the AQA Alliance, nor other national organizations have established standards or guidelines regarding an issue, to 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. Effective date: September 1, 2025.